Skin Assessment Questionnaire

Skin Assessment Questionnaire

Please complete this comprehensive questionnaire to assist us in model selection and treatment planning. Your responses will remain confidential and help us tailor our approach to your needs.
Consent
I have read and agree to the above consent statement.*

I agree
Personal Details
Full name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Phone number*
Please enter a valid phone number.Format: (000) 000-0000.
Email address*
example@example.com
Suburb / City and State
Age
Gender

FemaleMaleNon-binaryPrefer not to sayOther
Previous Model Experience
Have you previously been a model for a skin treatment case study?

YesNo
If yes, please describe (event name, year, treatment type)
Skin Profile
How would you describe your skin type day-to-day?

OilyDryCombinationSensitiveNormalOther
How would you describe your skin tone? (Fitzpatrick scale)

Type I (Very fair, always burns)Type II (Fair, usually burns)Type III (Medium, sometimes mild burn)Type IV (Olive, rarely burns)Type V (Brown, very rarely burns)Type VI (Dark brown or black, never burns)
How does your skin generally feel throughout the day?

TightOilyBalancedFlakySensitiveOther
Overall, how satisfied are you with your skin right now?
Describe your skin in your own words. What bothers you most?
Which of the following do you currently experience?

Acne / breakoutsRedness / sensitivityPigmentation / uneven toneDrynessOilinessFine lines / wrinklesScarringOther
What is your single most important concern — the one you most want addressed?
How long have you been experiencing your primary skin concern?
Rate the severity of your main concern
Does your skin concern affect your confidence or daily life?
Are there specific areas of your face or body where your concerns are concentrated?

ForeheadCheeksNoseChinJawlineNeckBackChestOther
Other body area — please specify
Treatment & Skincare History
Have you ever had professional skin treatments?

YesNo
Please describe any treatments you have had and the results — what helped, what did not, and any reactions
Have you had any injectables (anti-wrinkle or dermal filler) in the past 3 months?

YesNo
If yes, product, area treated, and approximate date
Are you currently using any prescription skincare?

YesNo
Other prescribed topical — please describe
Please describe your current daily skincare routine (morning and evening)
Do you wear SPF daily?
Medication & Health
Are you currently taking any oral medications?

YesNo
Other long-term medication — please describe
Do you have any diagnosed skin conditions?

YesNo
Do you have any known allergies — skincare, food, latex, or other?
Are you currently pregnant or breastfeeding?
Do you have a history of keloid scarring or abnormal wound healing?
Do you have a history of cold sores / herpes simplex outbreaks?
Other health conditions, surgeries, or medical history we should be aware of
Lifestyle & Habits
How would you describe your diet overall?
How much water do you drink on average each day?
How many hours of sleep do you get on average per night?
Rate your typical stress level day-to-day
Do you notice your skin worsens during periods of high stress?
How would you describe your exercise habits?
Do you smoke or vape?
How much alcohol do you consume weekly?
Do you experience any gut health or digestive concerns?

YesNo
Do you take any supplements? If so, which ones?
Do you believe your diet or lifestyle contributes to your skin concerns? Please explain.
Treatment Preferences & Availability
What outcome are you hoping to achieve through this treatment journey?
Are there any treatments you are not willing to have?

Chemical peelsSupplements3rd party laser3rd party IVOther
Other restrictions — please describe
How willing are you to make lifestyle changes as part of your treatment?
How available are you for appointments over the coming months?
Are you comfortable being photographed before, during, and after treatments for professional documentation?
If yes, conditions on photography
Is there anything else you would like us to know about your skin, health, or history that has not been covered?
Should be Empty:

Skin Assessment Questionnaire

Consent

Personal Details

Previous Model Experience

Skin Profile

Treatment & Skincare History

Medication & Health

Lifestyle & Habits

Treatment Preferences & Availability